What is the most important thing about you that I should know about you at this moment in your life?(required)

Are you currently in treatment/therapy for a mental illness? If yes, please provide their contact information.(required)

Are you on any medication? If so, please list all here(required)

What are the top 3 issue areas in your life that are of concern to you?(required)

Provide at least 2 things that you are currently doing to resolve or work through these issues? How would you rate the outcome?(required)

Are you committed to working through the areas identified as challenged until resolution is reached? This includes successfully completing each session, assigned readings and assignments, and reflective work to change your perspective?(required)

**Once you have completed this form, I will contact you for further instructions for receiving Individual GriefTalk Grief Recovery Services.